Out of all the fields of medical practice, the field of psychiatry is the most unlikely place to be wearing a mask. My fellow physicians in hospitals, operating rooms and clinics typically had masks ready to utilize for several procedures long before COVID emerged. In mental health care, especially as a child psychiatrist, masks are a significant hindrance in clinical care. How could the family that uses American Sign Language read my lips? How can I assess for autism spectrum disorder if they can’t see my facial cues? How can I spend another hour repeating myself to Cyracom because their phone interpreter did not hear me through the mask — again? How can I build rapport and trust with my eyes alone? So, you would think that the recent CDC recommendations to reduce mask-wearing would come as a great relief for a psychiatrist like me. Instead, I find myself a little panicked to get rid of the PPE that has plagued our lives for the past 2-plus years. As a psychiatrist in training, one of the things you are trained to do, is to develop your poker face. When patients speak to you, particularly if they are speaking about their trauma or delicate psychiatric symptoms, you are to be a blank slate. Nothing should get a rise out of you. Nothing should surprise you. Nothing should garner sudden empathy or even tears from you. While in fellowship, one of my attendings reminded me: “As a psychiatrist, nothing should shock you.” An expression of your own emotion may affect how and what that patient is willing to share with you. In other words, we as psychiatrists retain our own emotions to honor what our patients feel. We restrict our instinctual human response to permit the space for our patients to express themselves fully. Neurologists would call this “hypomimia” or “masked facies” that is a frequent sign of Parkinson’s disease. In psychiatry, we are trained to call this good practice. I have never been one to hold in my emotions easily. I am a hugger. I am a crier. I feel for people. So, developing this cool-façade-of-detached-caring-while-intently-listening was a real challenge for me. But once I learned it, it stuck. As an outpatient psychiatrist, I have found myself holding my reactions still within my face for 12 hours or more a day. I have now had ample practice. And it has been utterly exhausting. Ironically, when the “mask on” for COVID started and I continued to see patients in person, a sense of relief washed over me. I no longer had to hold my emotions back. I could open my mouth wide in surprise. I could purse my lips in annoyance and irritation. I could chuckle to myself. Finally, with a mask on, I found that my emotions and reactions had room to breathe. A sense of safety developed from wearing a mask that had nothing to do with really protecting me from the virus. It was the safety of being more emotionally present. To my great surprise, wearing a mask has even developed my skills as a clinician. Behind the mask, I have permission to be more honest with my reaction. As a result, I have relaxed and feel more responsive to my patients’ struggles and suffering, which have been amplified tremendously by the strain of the COVID pandemic and its psychosocial consequences. I have also been forced to develop other ways to express myself. My eyebrows can now raise to inquire further. My hands have evolved to demonstrate graphs and neurotransmitter action more elegantly. My voice has become a bit more animated and expressive to show empathy and compassion. The amount of human suffering and strain has significantly escalated during this pandemic: Parents dying in the hospital without being able to say goodbye to their children. Families losing their houses and unable to afford rent. Mandated quarantines for asymptomatic children pressuring working parents to stay home and play both employee and teacher at the same time. The guilt of indulging your child in too much screen time and then weathering the stormy aftermath of explosive anger when it is restricted. The persistent unknown of another strain provokes further restrictions. The underlying question without a clear answer is still: “Are we doing the right thing?” It has been a blessing on most days to have my own authentic response while bearing witness to these everyday tragedies. My clinic, like so many, has now made it the choice for both families and staff to choose whether to wear a mask if they are vaccinated. Most of the staff have found this decision liberating. But for me, it has been anxiety-provoking. Now that the mask mandates are lifting, I feel torn. I have thoroughly poked holes through my psychiatric poker face. I can’t fix my face anymore! What’s a good shrink to do? Try to regain the façade of quiet cool? Or express the empathy that has been unmasked during COVID? This week, I found myself in my office with a parent and patient— an anxious dad and his bright and bubbly, albeit shy, preteen. Many families still prefer their providers to wear a mask. I have no way to know who carries what political or health views around their mask-wearing. Their masks were off, and mine was on. When I asked them for their preference of whether they feel comfortable with me wearing a mask or not, the parent’s response was: “Whatever you want. It doesn’t really matter.” But it does matter. Doesn’t it? It matters if you feel comfortable and safe. It matters if I am an agent of viral infectivity. It matters if you want to be able to read my emotions as much as I need to read yours. It matters if your child has autism, is hearing impaired, or even if English is your second language. It matters if we want to “get back to normal.” But for all the reasons listed above, I find that I don’t want to lift my mask just yet. Given a choice, I find myself behind the mask still. At least, for now, this continues to give me the semblance of safety: to wear my heart on my sleeve and my emotion on my face. I will not feel guilty about this. I am just a psychiatrist presenting emotion. PPE for me. Source
